All Policies and Precertification
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Experimental/Investigational services are defined as a treatment, procedure, facility, equipment, drug, service or supply (“intervention”) that has been determined not to be medically effective for the condition being treated.
This policy addresses services considered to be experimental/investigational and, therefore, non-covered services.
Charges submitted for the services listed in this policy are denied as experimental/investigational. The determination for denial is based on ANY of the following reasons:
The following procedure codes are considered experimental/investigational and, therefore, non-covered. Scientific evidence of safety and efficacy has not been proven.
Internal Medical Policy Committee 1-22-2020 new code update
Internal Medical Policy Committee 7/22/2020 Coding update for July HCPCS
Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.
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